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Urology. 2009 August ; 74(2): 283–287. doi:10.1016/j.urology.2009.02.011.

Trends in the Surgical Management of Stress Urinary

Incontinence among Female Medicare Beneficiaries
Jennifer T. Anger1, Aviva E. Weinberg1, Ariana L. Smith1, Michael E. Albo2, Ja-Hong Kim1,
Larissa V. Rodríguez1, Christopher S. Saigal1, and the Urologic Diseases in America
Project
1UCLA, Los Angeles, CA

2UCSD, San Diego, CA

Abstract
Objectives—To identify patterns in the surgical management of women with stress urinary
incontinence in the United States from 1992 to 2001.
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Methods—As part of the Urologic Diseases in America Project, we analyzed data from a 5%
national random sample of female Medicare beneficiaries age 65 and older. Data were obtained
from the Centers for Medicare and Medicaid Services carrier and outpatient files from 1992, 1995,
1998, and 2001. Women in the sample with a diagnosis of urinary incontinence were identified by
ICD-9 codes. Surgical procedures were identified by CPT-4 codes. Patterns of care were then
analyzed over the 10-year period.
Results—The overall number of surgical procedures increased from 18,820 to 32,480 over the
10-year period, likely due to the growing population of Medicare beneficiaries. The needle
suspension was the most commonly performed incontinence procedure in 1992 and 1995, while
collagen injection gained rapid popularity and became the most common procedure in 1998. A
drastic increase in the numbers and rates of slings occurred between 1995 and 2001.
Conclusions—The 1990s saw a rapid shift in the surgical management of stress urinary
incontinence. The rapid increase in utilization of sling procedures corresponded with a decrease in
utilization of the many other available anti-incontinence procedures. As in years prior, we
identified a trend toward minimally invasive approaches to surgery, without the presence of
randomized controlled clinical trials to support these trends. We anticipate that analysis of
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Medicare claims from 2004 and onward will demonstrate a further increase in the use of sling
procedures.

Keywords
claims data; sling; stress incontinence; surgery

© 2010 Published by Elsevier Inc.

Corresponding author: Jennifer Anger, MD, MPH, Assistant Professor of Urology, UCLA Department of Urology, 1260 15th Street,
Suite 1200, Santa Monica, CA 90404, Tel: (310) 451-8751, FAX: (310) 394-5302, janger@mednet.ucla.edu.
Presented at the 2009 Society for Urodynamics and Female Urology and American Urological Association Annual Meetings, and the
NIDDK New Research Directions in Urinary Incontinence Symposium, 2008
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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 Anger et al. Page 2

INTRODUCTION
The treatment of stress urinary incontinence (SUI) encompasses both behavioral as well as
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surgical therapies. For women who continue to suffer from symptoms of incontinence after
non-surgical management, there exists an array of surgical options. The surgical treatment
for incontinence has evolved rapidly for several decades, when controversies over which
approach was optimal engendered debate between proponents of different procedures. Over
the years, various surgical treatments have fallen out of favor while newer methods have
risen to the forefront. We hypothesize that the relatively minimal morbidity of the sling
procedure along with the publication of several large case series documenting its
effectiveness would make the sling the most common anti-incontinence procedure. In this
study we used Medicare claims data to analyze and explain treatment trends in the surgical
management of stress urinary incontinence over the 10-year period between 1992 and 2001.

MATERIAL and METHODS

The use of Medicare claims data allows for the assessment of medical care for a large,
heterogeneous, nationwide sample of the population across various clinical settings. We
analyzed claims data for 1992, 1995, 1998, and 2001 from the Centers for Medicare and
Medicaid Services (CMS) to estimate utilization of surgical procedures for stress
incontinence by the female Medicare population age 65 and over with an International
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Classification of Diseases, 9th edition (ICD-9) code for urinary incontinence (Appendix 1).
Data on surgeries performed were obtained from the Medicare Provider Analysis and
Review (MEDPAR) files, which contain records of hospital inpatient services, as well as
CMS outpatient and ambulatory surgery files. Enrollment information on Medicare
beneficiaries was obtained from the CMS Denominator file. Data from these files were
linked to determine utilization in the inpatient, ambulatory surgery center, and hospital
outpatient settings.

Data was obtained from a 5% national random sample of Medicare records. National
estimates of service use were then obtained by multiplying counts by a constant weight of
20, as previously described1. Treatments were identified by Current Procedural
Terminology, 4th edition (CPT-4) procedure codes reflecting physician billing, combined
with ICD-9 procedure codes (ICD-9 CM), reflecting hospital billing. Treatments were
stratified into treatment types (Appendix 2).

RESULTS
During the 10-year period between 1992 and 2001, the overall number of surgical
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procedures performed for stress urinary incontinence increased from 18,820 to 32,480
(Table 1). The rates of surgical procedures per 100 women actually decreased slightly from
1992 to 2001. In 1992, the most common surgical procedure for SUI was the needle
suspension (7,840 procedures, or 2.4 procedures per 100 Medicare beneficiaries with a
diagnosis of incontinence) followed by the anterior urethropexy (7,080). Only a small
number of slings (640) were being performed in the early 1990’s, and both laparoscopic and
collagen injections had yet to enter the anti-incontinence armamentarium. In 1995, the
needle suspension still remained the most common surgical procedure for stress urinary
incontinence, with 10,540 procedures performed in that year.

Between 1995 and 1998, collagen injection began to rise quite rapidly in popularity and
became favored over previously common procedures such as the needle suspension, while
the urethropexy remained the same. In 1998, 12,040 (3.7 per 100 women) injections were
performed in this population of Medicare beneficiaries, making collagen injections the most

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popular anti-incontinence treatment in the late 1990’s. In this same year, the number of
needle suspension procedures declined precipitously to 5,160 procedures, its numbers less
than half of what they were in 1995. The popularity of collagen injections was short-lived.
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By 2001, the pubovaginal sling (CPT-4 code 57288) swiftly rose to the forefront and
became the dominant surgical procedure for stress urinary incontinence, with 17,680
procedures performed that year alone. This drastic increase in utilization of sling procedures
between 1992 and 2001 corresponds to a steady decline in once commonplace procedures
such as the needle suspension and the anterior urethropexy (Table 1).

COMMENT
This study demonstrates important trends in the management of stress urinary incontinence
over a ten-year period. The overall number of surgical procedures performed for stress
urinary incontinence increased during the 10-year period between 1992 and 2001. This was
likely due to the rapidly growing population of Medicare beneficiaries during that
timeframe. Also, increased physician and patient awareness of urinary incontinence may
have led to more procedures performed overall.

Throughout the history of the surgical management of SUI, one procedure after another
gained popularity and ultimately faded into relative disuse, without the presence of strong
evidence to support these changes. For the procedures studied, evidence-based
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recommendations are lacking due to the limited number of randomized clinical trials
comparing the various surgical procedures and the absence of standardized outcome
measurements across study designs 2,3. Despite this, drastic shifts in utilization of the
various surgical options occurred, reflecting new technology and a quest for procedures that
are less invasive, less morbid, and ultimately more efficacious.

Kelly Plication
The first effective surgical treatment for stress urinary incontinence, the Kelly plication, was
published in 1914 by Kelly and Dunn, and remained the leading treatment for many years.
This operation was developed as a corrective procedure for incontinence associated with a
cystocele4,5. In a Cochrane literature review of anterior colporrhaphy with Kelly plication,
10 studies involving 1012 women showed that anterior repair was less effective than
retropubic approaches for the treatment of SUI, even in women with concomitant
genitourinary prolapse.6 As a result, current practice guidelines for the treatment of genuine
SUI recommend against the use of the Kelly plication.2

Anterior Urethropexy
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The Marshall-Marchetti-Krantz (MMK) anterior urethropexy, first performed for the

treatment of stress incontinence in 1944, involves the direct fixation of the urethra and
bladder to the periosteum of the symphysis pubis.78 In a 1956 article review by Mainprize
and Drutz, the success rate for the 2,712 MMK procedures performed through 1988 was
found to be as high as 86.1%.9 However, the complications associated with periosteal suture
placement, the approach’s inability to effectively reduce a cystocele,10 and the procedure’s
higher long-term failure rate of 36.1% (compared to the Burch failure rate of 15.2%)11 led to
the decline in its popularity. The Burch retropubic urethropexy is perhaps one of the most
extensively studied surgical procedures for SUI, and has become the “gold standard”
procedure against which other operative managements of SUI are now compared. The
Burch, first performed in 1958, was developed as a modification of the MMK. It eliminated
the complication of osteitis pubis and also provided an approach that could concurrently
manage a cystocele.10 In a Cochrane review of the literature including 39 trials and

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involving a total of 3301 women, they found overall cure rates were 69% to 88.0% at
follow-up of one to five years.12.
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Needle Suspensions
The Pereyra needle suspension was introduced in 1959 as an improvement upon the MMK
retropubic urethropexy.13 The operation has been modified several times over the years by
Pereyra and others such as Stamey, Raz, and Gittes14,15. For years, needle suspensions were
considered the most appropriate treatment for cases of SUI associated with urethral
hypermobility. In a 2004 Cochrane review looking at nine trials of 784 women who
underwent open retropubic suspension or needle suspension operations, found that needle
suspensions had a higher one year failure rate, 29% versus 16%.16 Bergman et al. also found
that the Pereyra procedure had a lower cure rate compared with Burch suspension, 43% vs.
82% at five years, respectively.3 Due to its high failure rate and poor long-term results, the
needle suspension has fallen out of favor for the treatment of SUI.

Periurethral Bulking agents

The use of injectable materials into the urethra for the management of stress incontinence
traces back to the 1930’s.17 Collagen injections are currently the most widely used injection
material.2 Injections offer distinct benefits over surgery, as they can be done on an
outpatient basis and have allowed urologists to expand incontinence treatment to women
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who are not ideal surgical candidates due to advanced age or medical comorbidities. In a
cohort study of 181 women with genuine SUI by Herschorn et al., 23% of patients were
cured, 52% had significant improvement and 25% failed collagen injections entirely17. A
Kaplan-Meier curve generated from their study population demonstrated that the probability
of remaining continent without additional collagen injections was 72% at 1-year, 57% at 2-
years, and 45% at 3-years.17 Although suburethral injections had a rapid rise and subsequent
decline in popularity, they will likely remain an important adjunct for the treatment of SUI
in select patient populations.

Sling
The sling procedure has undergone many modifications in both technique and materials over
the years, from autologous rectus fascial slings to minimally invasive mid-urethral synthetic
slings. Until recently there we no rigorously designed trials to compare what had become the
two gold standard procedures for the treatment of SUI, the sling and the Burch
colposuspension. However, Albo et al. performed a multi-center randomized control trial of
655 women, comparing Burch colposuspension with the autologous pubovaginal sling.18
They found higher success rates for the sling group in both overall incontinence measure as
well as stress incontinence specific measures. At 24 months follow-up, women in the
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pubovaginal sling had a 66% success rate for stress incontinence compared to the Burch’s
49% rate of success. However, the study did find that pubovaginal sling procedures were
more frequently complicated by minor complications such as voiding dysfunction, urge
incontinence and recurrent urinary tract infections. Despite this increased morbidity rate,
slings have clearly demonstrated increased efficacy and ease of placement, making them the
current gold standard in the treatment of stress urinary incontinence.

Limitations
The use of Medicare claims data allows for the assessment of medical care for a large,
heterogeneous, nationwide sample of the population across various clinical settings.
However, claims-based data is reliant on CPT-4 codes, and therefore is subject to
inaccuracies. For example, the codes used for anterior urethropexy included patients
receiving both an MMK procedure and a Burch colposuspension. Therefore we could not

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compare treatment patterns between these two procedures. Also, clinicians may choose a
different code for the same procedure. We did not include patients who underwent a
combined anterior colporrhaphy and urethropexy (CPT-4 code 57289), because this code
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does not differentiate those who underwent an isolated cystocele repair from those who
underwent a combined urethropexy and cystocele repair. Hence, we did not include all
Medicare beneficiaries who underwent urethropexies.

Also, we could not differentiate between bladder neck fascial slings and midurethral
synthetic slings. Although the use of midurethral synthetic slings has likely surpassed
bladder neck slings, we could not determine the frequency of each type of procedure given
that they share the same CPT code. Nonetheless, we can see how SUI management trends
clearly reflect the desire for lower morbidity and high efficacy on the part of urologists and
gynecologists.

CONCLUSIONS
Despite the relative lack of randomized clinical trials comparing various anti-incontinence
procedures, the 1990’s witnessed a dramatic wave of change in the surgical management of
stress urinary incontinence in women. In the period from 1992-2001, procedures such as the
needle suspension, MMK anterior urethropexy, and Kelly plication were superseded
temporarily by less invasive procedures such as collagen injections and eventually entirely
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overwhelmed by sling procedures. In tracing through the historical trends in the surgical
management of stress incontinence, it becomes obvious that the popularity and decline of
various surgical options is only partially explained by the relevant scientific literature.
Instead, these swings in practice may reflect a widespread surgical evolution towards more
minimally-invasive procedures that have lower patient morbidity yet durable efficacy.
Ultimately, the rapid rise in sling procedures over the 1990’s best attests to physicians’ and
patient’s preferences for procedures that engender these qualities.

Appendix 1

ICD-9 Codes for Urinary Incontinence

596.51 Hypertonicity of bladder

596.52 Low bladder compliance
596.59 Other functional disorder of bladder
599.8 Other specified disorders of urethra and urinary tract
599.81 Urethral hypermobility
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599.82 Intrinsic (urethral) sphincter deficiency (ISD)

599.83 Urethral instability
599.84 Other specified disorders of urethra
625.6 Stress incontinence, female
788.3 Urinary incontinence
788.30 Urinary incontinence unspecified
788.31 Urge incontinence
788.33 Mixed incontinence, male, female
788.34 Incontinence without sensory awareness
788.37 Continuous leakage

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Appendix 2

ICD-9 CM and CPT codes for Stress Urinary Incontinence Surgeries

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Surgical Procedure CPT code ICD-9 CM code

Anterior Urethropexy 51840 simple 59.5

(Marshall-Marchetti-Krantz/Burch) 51841 complicated

Abdomino-vaginal vesical neck suspension 51845 59.5

(Stamey, Raz, modified Pereyra)

Laparoscopic urethral suspension 51990 59.5

Laparoscopic sling procedure 51992

Injection of implant into urethra/bladder neck 51715 59.72

(Collagen implant)

Vaginal hysterectomy with colpo-urethropexy 58267 70.51 anterior colporrhaphy with

(MMK/Burch) urethrocele repair
68.5 vaginal hysterectomy
Sling operation for stress incontinence, fascia or synthetic 57288 59.5

Plication of urethrovesical junction 57220 59.3

Kelly plication

Acknowledgments
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Funding: NIDDK, Urologic Diseases in America Project

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6. Glazener CMA, Cooper K. Anterior vaginal repair for urinary incontinence in women. Cochrane
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Table 1
Rate of surgical procedures used among female adult Medicare beneficiaries with a diagnosis of urinary
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incontinence, counta (rateb)

PROCEDURE 1992 1995 1998 2001

Anterior Urethropexy (e.g. Burch/MMK) 7,080 (3.9) 8,180 (3.3) 7,800 (2.4) 4,220 (1.2)

Hysterectomy with Colpo-Urethropexy (e.g. Burch/MMK) 1,920 (1.1) 2,220 (0.9) 1,480 (0.5) 2,120 (0.6)

Needle-type suspension 7,840 (4.4) 10,540 (4.2) 5,160 (1.6) 1,400 (0.4)

Laparoscopic Repair 0 (0.0) 0 (0.0) 0 (0.0) 280 (0.1)

Collagen Injection 0 (0.0) 9,300 (3.7) 12,040 (3.7) 6,340 (1.7)

Pubovaginal Sling 640 (0.4) 1,560 (0.6) 9,160 (2.8) 17,680 (4.9)

Kelly Plication 60 (0.0) 260 (0.1) 220 (0.1) 180 (0.1)

TOTAL 18,820 (10.5) 32,880 (13.1) 36,400 (11.1) 32,480 (9.1)

a
Unweighted counts multiplied by 20 to arrive at numbers in the table
b
Rate per 100 female adult Medicare beneficiaries with a diagnosis of urinary incontinence
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